Frontiers in Emergency Medicine
Volume:4 Issue: 4, Autumn 2020

Point-of-care hemoglobin testing devices can help emergency physicians to make their clinical decisions in a timelier manner.  They can also improve the patient care process by decreasing the length of stay and costs. Although different devices are available now, their diagnostic accuracy remains still uncertain. 

This study compares the results of hemoglobin levels measured by a point-of-care hemoglobin testing device and central lab auto-analyzer. 

Hemoglobin level was measured both by a point-of-care device (Mission® Plus Hb) and the central laboratory auto-analyzer (Sysmex KX-21N™) in medical cases presenting to emergency department (ED) and requiring hemoglobin (Hb)/hematocrit (Hct) level measurement. The agreement of Hb and Hct between the two methods was assessed based on intraclass correlation coefficient (ICC), Bland-Altman analysis and the Mountain plots. Also, time gap between point-of-care testing and preparation of central lab results was measured. 

Hb and Hct were measured in 86 cases mostly presented because of gastrointestinal bleeding. We found a good agreement between the two methods for hemoglobin (ICC=0.985) and hematocrit levels (ICC=0.991). The bias was 0.09 and 95% limits of agreement (LoA) were -0.89 to 1.07 for Hb level. Mean of time delay between point-of-care testing and preparation of central lab results was 207.31 minutes (SD=93.66) and this delay was clinically significant (p=0.001). 

Point-of-care measurement of Hb level provides proper quantitative results in ED patients. It significantly decreases laboratory turnaround time and may be used to improve the patient throughput by decreasing the length of stay in most clinical settings.

Aspiration of gastric contents is one of the most important complications during procedural sedation and analgesia (PSA). It seems that gastric ultrasonography could be a suitable tool for qualitative and quantitative measurement of gastric contents before PSA. 

In the present study, efforts were made to assess the correlation between ultrasonographic gastric antral area and incidence of vomiting in patients underwent PSA. 

In the present cross-sectional study, using a convex 4MHz probe in supine position, ultrasonographic evaluation of gastric antral area was done for 100 participants in need of PSA. The evaluations were done from the outer layer of the gastric wall and 3 images were recorded between peristaltic contractions. Finally, the rate of vomiting incidence in patients were recorded and compared with the results of patients’ ultrasonography. 

The findings showed that anteroposterior diameter (AP), craniocaudal diameter (CC), and cross-sectional area (CSA) had a statistically significant correlation with incidence of vomiting in patients (p ≤ 0.0001). The odds ratio of these variables show that increase in antral diameter leads to increase incidence of vomiting. Based on these findings, 1 unit rise in AP increases the odds of vomiting by 7.45 times, 1 unit increase in CC increases the odds by 7.20 times, and finally, 1 unit increase in CSA increases the odds of vomiting by 1.32 times. 

Gastric antrum ultrasonography can be used as a proper diagnostic tool for assessing the risk of vomiting in patients undergoing PSA.

Limb trauma is one the main causes of emergency room (ER) referrals and patients often complain of pain from the very moment of arrival.

We decided to compare the analgesic effect of ketamine nebulizer with intravenous (IV) morphine in trauma patients referred to ER. 

In this clinical trial study trauma patients referred to ER of Alzahra and Kashani hospitals in Isfahan, Iran were selected. All trauma patients older than 18 years with limb pain who had a pain score ≥ 7 based on visual analogue scale (VAS) criteria were included. During pre-hospital management, patients were divided into two groups of receiving ketamine nebulizer with a dose of 1.6 mg/kg and receiving IV morphine with a dose of 0.1 mg/kg. Pain score, vital signs and complications were recorded 5 and 15 minutes after receiving the first dose of drug and also at the time of arrival to ER. 

Finally, the records of 391 patients were analysed. There was no significant difference between the two groups in terms of pain intensity, vital signs before intervention, the first 5 and 15 minutes after and the time of arrival in ER (P>0.05). But the changing of VAS scores in different times was significant in both groups (P<0.001). There was a significant difference between the two groups in complications including nausea and vomiting (P<0.001), and also delirium (P=0.010). 

Using ketamine nebulizer can produce similar analgesic effects as IV morphine in trauma patients referred to ER.

Although narcotics are effective for pain relief in these patients, they have little impact on the underlying cause. Therefore, surveys have been conducted to find more effective agents. 

This study conducted to compare the analgesic effect of aminophylline and hyoscine combination with morphine on renal colic patients. 

This double-blind clinical trial was conducted on patients with renal colic caused by urinary tract stones. Subjects were selected via convenience sampling method. Patients were randomly divided into two groups based on whether they received aminophylline + hyoscine or morphine. Before drug administration, one researcher was asked to measure the pain of the patients using Graduated Numbered Visual Analogue Scale (GN-VAS). Afterward, 20 mg of hyoscine along with 3 mg/kg of aminophylline in 100 cc normal saline was injected during 10 minutes into patients in the one group, whereas 0.1 mg/kg of morphine was intravenously with 100 cc normal saline to align two groups, administered to the subjects in another group. Half an hour after the administration of drugs, pain was measured for the second time. Vital signs and side effects were all recorded. 

In this study, 95 patients (47 patients in the aminophylline+hyoscine group and 48 patients in the morphine group) remained in the trial until the end. The difference in sex distribution(p=0.227) and age(p=0.680) of the two groups was not statistically significant. Median of pain intensity was not significantly different between the two study groups (p<0.05), neither before nor after administration of the drugs. The mean time required for pain relief in morphine group was significantly lower than aminophylline+hyoscine group (5.9±1.6 vs. 11.1±1.6 minutes; p<0.001). 

Overall, our findings indicated that aminophylline + hyoscine combination was effective in reducing renal colic pain and there is no significant difference between this combination and morphine in terms of pain relief.

Although some countries have set up predetermined programs and specialized teams to deal with hazardous materials (Hazmat) induced events, in other countries including Iran there are many weaknesses in this regard. 

We aimed to develop the necessary indicators for the formation of teams to deal with Hazmat accidents in the health system based on existing standards and resources as well as the indigenous conditions of Iran. 

This cross-sectional study was carried out in two stages from 2018 to 2020.  In the first stage, the literature review was performed and the current guidelines, standards, and models presented in other countries were reviewed and related items were extracted. In the second stage, semi-structured and purposeful interviews by managers and physicians specialized in Hazmat incidents working in Iran, were conducted. The interviews were recorded and later the recordings were transcribed and simultaneously the categorizing and coding of the interviews were performed. 

In the first stage, searching through the available resources for the present study identified 12 published references through which 10 indicators to develop a Hazmat team were ultimately extracted. In the second stage, a total of 10 interviews were conducted and data saturation occurred. Based on the results of the content analysis for the main indicators of designing and developing teams, 8 categories and 19 sub-categories were developed. 

By interviewing and localizing the 10 main indicators that were achieved in the first stage, we finally reached the 8 indicators including: Training hazmat team’s members, required equipment for team, response plan, medical surveillance program, hazmat team structure, incident command system, hazmat team qualification of different levels, certification and maintenance of the certificate.

Coronary artery disease (CAD) is a costly problem and its presentations and risk factors may differ by sex. 

This study aimed to evaluate the risk factors profile and angiographic pattern of the patients undergoing coronary angiography, according to their gender.

This cross-sectional study was conducted on 741 patients who were referred for coronary angiography from March to August 2018 at Imam Ali cardiovascular center, western Iran. Using a checklist, we collected the demographic, clinical, biochemical, and lab parameters and angiographic findings in these patients. Also, differences between groups were compared using Chi-square and independent t-tests. 

Women were different from men in terms of the prevalence of hypertension (71.7% vs. 45.3%), diabetes mellitus (34.9% vs. 17.8%), and hypercholesterolemia (26.4% vs. 17.1%). Whereas, men were more likely to be smoker (28.7% vs. 0%) and obese (42.09±16.68 vs. 29.12±4.72). Total Cholesterol and Triglycerides were higher in women compared to men, which were statistically significant. Glucose plasma was significantly higher in women compared to men (p=0.01).  Both atherogenic (low-density lipoprotein (LDL)) and protective (high-density lipoprotein (HDL)) cholesterol were higher in women than men. Women were more likely to take antiplatelet (i.e. Aspirin) and antihypertensive therapies (i.e. beta-Blocker, angiotensin receptor blockers (ARBs), and angiotensin converting enzyme (ACE) inhibitors) than men. Also, it was shown that, Men were more likely to have two-vessel disease (p=0.041) and three-vessel disease (P=0.013) compared to women. Disease in the right coronary artery (RCA) (28.9% vs. 14.4%), circumflex (LCx) (26.0% vs. 15.3%), and left anterior descending (LAD) (37.8% vs. 26.4%) was more plausible to occur in men compared to women (p≤0.05). 

Access and use of health care programs are needed to control CAD risk factors. The findings of the current study showed the significance of gender in the extent of coronary artery blockages.

To save lives and reduce the disability and death of the patients, emergency medical technicians (EMTs) must make timely decisions in complex and, sometimes, life-threatening situations. Since the pre-hospital decision-making is a continuous and important process. 

The present study aims to identify the factors affecting EMTs’ on-scene decision-making in emergency situations. 

A qualitative approach using in-depth semi-structured interviews and field observations was employed to explore the factors influencing EMTs’ on-scene decision-making in emergency situations. Purposeful sampling was performed with 19 participants including 12 EMTs, 3 dispatchers, 3 medical directions physicians and one EMS manager as a policy maker. Interviews were conducted from October 2018 to March 2018 and the data were analyzed using Graneheim and Lundman’s content analysis approach. 

Eight categories and 18 sub-categories emerged to describe the factors effective in emergency medical technicians’ on-scene decision-making. they  were cultural context (community’s culture and organizational culture), interactions (malingering, threat and violence and considerations), competencies (acquisitive and intrinsic); personal feeling (positive feeling and negative feeling), authority (structural and in processing),  education (public and professional), special conditions (patient’s clinical situation, weather conditions, mission’s time and mission’s location), and organizational resource (facility and equipment, and human resources). 

To facilitate EMTs’ on-scene decision-making, it is recommended to clarify the EMTs’ responsibilities, promote the community’s culture, modify people’s expectations, police monitoring and control and value the star of logo on EMTs' uniform. The EMTs’ on-scene decision-making process should also be explored.

 Limitations of Glasgow coma scale (GCS) led the researchers to designing new physiologic scoring systems such as revised trauma score (RTS), rapid acute physiology score (RAPS) and rapid emergency medicine score (REMS), and worthing physiological scoring system (WPSS). However, it is not yet known whether these models have any advantage over GCS. 

The present study attempted to compare the values of 4 physiologic scoring systems including RTS, RAPS, REMS and WPSS with GCS in predicting in-hospital mortality of trauma patients. 

The present diagnostic accuracy study was performed on trauma patients presenting to emergency departments of 4 hospitals in Iran throughout 2017. Patients were clinically evaluated and were followed until discharge from hospital. Finally, the status of patients regarding mortality and poor outcome (death, vegetative status, severe disability, and moderate disability) was recorded and predictive value of GCS was compared with physiologic scales. 

Area under the ROC curve of GCS in prediction of in-hospital mortality was not significantly different from that of REMS (0.89 vs. 0.91; p=0.298), RAPS (0.89 vs. 0.88; p=0.657), and WPSS (0.89 vs 0.91; p=0.168) but was significantly more than RTS (0.89 vs. 0.85; p=0.002). In addition, area under the ROC curves of GCS, REMS, RAPS, WPSS and RTS in prediction of poor outcome were 0.89, 0.88, 0.88, 0.91, and 0.81, respectively. Area under the ROC curve of GCS in prediction of poor outcome did not differ from area under the ROC curves of REMS (0.89 vs. 0.88; p=0.887), RAPS (0.89 vs. 0.88; p=0.601) and WPSS (0.89 vs. 0.91; p=0.113) but was significantly higher than RTS (0.89 vs. 0.81; p<0.0001). 

Findings of the present study indicated that GCS is still the best method for evaluating injury severity and trauma patients’ outcome in the emergency department; because it is easier to calculate and assess than many physiologic scales and it has a better performance in predicting in-hospital mortality and poor outcome compared to RTS.

Identifying predisposing factors of seizure can be somewhat helpful in preventing it from occurring. 

The present study has been designed aiming to assess the frequency of predisposing factors of seizure in patients visiting the emergency department (ED). 

The present prospective cross-sectional study was performed on adult patients presenting to ED following seizure during 1 year. Known or probable predisposing risk factors for seizure were extracted from various studies and were asked from patients or their relatives during history taking and clinical examination. 

Finally, 246 seizure patients with the mean age of 38.8 ± 18.3 (18 – 92) years were included (68.7% male). Most patients were in the 18–29 years age group (41.1%), had an educational level less than high school diploma (59.8%), and were unemployed (47.8%). Among the predisposing factors of seizure, emotional stress with 107 (43.7%) cases, insomnia with 44 (17.9%), and irregular use of antiepileptic medications with 36 (14.6%) cases were the most common predisposing factors, respectively. In 43.5% of the patients, no identified predisposing factor was found. Insomnia (p = 0.002), stress (p < 0.001), and substance abuse (p < 0.001) were the most important predisposing factors of seizure in individuals less than 60 years old. In addition, being in the menstruation period was also shown to be a predisposing risk factor for women aged less than 60 years (p = 0.002). 

Emotional stress, insomnia, and irregular use of antiepileptic medication were the most important predisposing factors of seizure in the studied patients. In more than 40% of patients presenting to ED following seizure, no predisposing factor was found.

Diabetic Ketoacidosis (DKA) is a well-known emergency in diabetic patients. In a subgroup of patients ketoacidosis is present but is not accompanied by the marked hyperglycemia considered part of the diagnostic criteria for DKA. This is known as Euglycemic DKA (EuDKA). Evidence acquisition: We searched the PubMed for the existing literature on the topic of normoglymic ketoacidosis, including its prevalence, pathogenesis, and treatment.  

The study showed that there are many reports of the cases in which diabetic patients developed ketoacidosis without experiencing hyperglycemia. Several predisposing factors have been proposed but the precise pathophysiologic mechanisms are still under investigation. Some pathways have been suggested. Timely diagnosis is of paramount importance. Treatment is similar to DKA. 

EuDKA is a medical emergency that should be considered when evaluating a diabetic patient with ketoacidosis. It should be diagnosed and treated promptly.

Although brain death has been extensively dealt within the contemporary literature, there does exist some ambiguities regarding its definition, clinical criteria, ethical and religious perspectives. The neurological criteria helped in subduing the much talked about issues of whole brain death and brainstem death to a greater extent, but the recently introduced cardiac or circulation death made the issue of brain death more complicated and indeed a conundrum. We would touch upon brain death issues since the terminology was initially introduced till the present day when the cardiac death connivingly made its way as a means of organ procurement in the so called dead patients. This review article is the authors' own perception and understanding of the conundrum of brain death, and should not be misinterpreted as a narrative or a systematic review of the subject. In conclusion, this review aims at filling the void that exists about the criteria for brain death in the contemporary literature.

ST-elevation in precordial leads is diagnostic for acute transmural myocardial infarction (MI) related to acute occlusion of left anterior descending artery (LAD). 

In this case report, a 54-year-old man was admitted to the emergency department (ED) due to chest pain. ST-depression with tall T waves in precordial leads was detected in surface electrocardiogram (ECG). Angiography showed acute total occlusion of proximal LAD and ad hoc percutaneous coronary intervention (PCI) was performed successfully. 

This case highlights that total occlusion of LAD may present without typical ST-elevation pattern in ECG.

This case emphasizes on the importance of detecting thrombosis and carotid artery injuries and the need for rapid treatment of blunt neck traumas. 

A 43-year-old male motorcyclist rider, rode into a rope and suffered blunt neck trauma. At admission to the emergency department (ED), he was fully conscious with Glasgow coma scale of 15. The biochemical tests and X-rays were normal, but initial examination revealed paresthesia in the right-hand fingertips, which exacerbated over the first 24 hours of admission. Doppler ultrasound of the neck arteries and computed tomography (CT) angiography reports showed thrombosis of the right common carotid artery, which spread to the right subclavian and vertebral arteries. Treatment was initiated with heparin injection followed by daily administration of oral warfarin, and seven days later, symptoms were relatively improved. 

Considering possible vascular injuries following blunt neck trauma should be kept in mind when dealing with such patients, and necessary physical examination required to rise the impression. By reviewing the literature, it seems that although CT angiography is usually used in screening carotid injuries, this modality appears to have poor sensitivity in this regard, and digital subtraction angiography (DSA) is still considered the gold standard for detecting carotid artery injury.

Ventriculoperitoneal (VP) shunt placement is the common treatment approach in children with hydrocephalus. Complications of VP shunt are not uncommon but some are unusual and rare. Except infection and obstruction, other complications of VP shunts are uncommon and distal catheter migration into scrotum is one of the rarest ones. 

Here we present a rare complication of VP shunt, distal catheter migration into scrotum, in 4 patients that presented with scrotal swelling or bulging in the inguinal region, who underwent surgery for replacment of the distal cathether in peritoneum and processus vaginalis repair. 

In patients with a history of VP shunt placement who candidate for surgery due to inguinal hernia or hydrocele, possible migration of distal catheter should keep in mind by the surgeon. This complication can occur as early as at the time of shunt placement or delayed.